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Kankam SB, Habibzadeh A, Amirikah MT, Mensah PKN, Fordjour CO, Mate-Kole MN, Danso SE, Jalloh M, Osifala O, Kwapong FL, Afriyie AA, Zeto R, Fokorede O. Enhancing stroke care in Ghana: A systematic review of stroke rehabilitation services. J Stroke Cerebrovasc Dis 2024; 33:107756. [PMID: 38710462 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Revised: 04/27/2024] [Accepted: 05/01/2024] [Indexed: 05/08/2024] Open
Abstract
OBJECTIVE In Ghana, the shifting demographics of stroke incidence towards young adults have prompted the expansion of stroke care and rehabilitation efforts. Nevertheless, the precise impact of stroke rehabilitation remains unclear. We conducted a systematic review to explore the landscape and effects of stroke rehabilitation in Ghana. METHOD We identified articles on stroke rehabilitation services in Ghana through searches of PubMed, Scopus, Embase, and Web of Science from inception until February 2024. The Critical Appraisal Skills Programme (CASP) Qualitative Checklist was employed to assess the risk of bias in the included studies, supplemented by qualitative synthesis. RESULTS Among the 213 articles screened, 8 were deemed suitable for review. These studies primarily focused on two groups: stroke survivors (n = 335) and healthcare professionals (HCPs) (n = 257). Many stroke survivors reported significant benefits from telerehabilitation, with increased participation in rehabilitation activities correlating with improved physical and cognitive outcomes. The findings also underscored a lack of knowledge about stroke rehabilitation among HCPs, alongside variations in the availability of protocols and guidelines for stroke management across different hospital levels. CONCLUSIONS The review reveals several challenges in stroke rehabilitation in Ghana, including disparities in HCPs' perceptions and utilization of rehabilitation services. The findings emphasize the need for comprehensive, patient-centered approaches, standardized training for HCPs, improved resource allocation, and the integration of telehealth to overcome barriers and enhance stroke rehabilitation in Ghana. These insights hold significance not only for Ghana but also for guiding strategies in similar contexts worldwide, aiming to improve stroke rehabilitation outcomes.
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Affiliation(s)
- Samuel Berchi Kankam
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard, Medical School, USA; Harvard T.H Chan School of Public Health, Harvard University, Cambridge, USA; Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.
| | - Adrina Habibzadeh
- Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran; USERN Office, Fasa University of Medical Sciences, Fasa, Iran
| | - Mike Tuffour Amirikah
- Harvard T.H Chan School of Public Health, Harvard University, Cambridge, USA; Department of Internal Medicine, University of Ghana Medical Center, Univerity of Ghana, Accra, Ghana
| | | | | | | | - Samuel E Danso
- Harvard T.H Chan School of Public Health, Harvard University, Cambridge, USA
| | - Mohamed Jalloh
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard, Medical School, USA
| | | | | | | | - Ruth Zeto
- General Medicine Division, Beth Israel Deaconess Medical Center, Boston, USA
| | - Olayinka Fokorede
- Harvard T.H Chan School of Public Health, Harvard University, Cambridge, USA
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Salunkhe M, Haldar P, Bhatia R, Prasad D, Gupta S, Srivastava MVP, Bhoi S, Jha M, Samal P, Panda S, Anand S, Kumar N, Tiwari A, Gopi S, Raju GB, Garg J, Chawla MPS, Ray BK, Bhardwaj A, Verma A, Dongre N, Chhina G, Sibia R, Kaur R, Zanzmera P, Iype T, Sulena, Garg R, Kumar A, Ranjan A, Sardana V, Maheshwari D, Bhushan B, Saluja A, Darole P, Bala K, Dabla S, Puri I, Shah S, Ranga GS, Nath S, Chandan S, Malik R. IMPETUS Stroke: Assessment of hospital infrastructure and workflow for implementation of uniform stroke care pathway in India. Int J Stroke 2024; 19:76-83. [PMID: 37577976 DOI: 10.1177/17474930231189395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
BACKGROUND India accounts for 13.3% of global disability-adjusted life years (DALYs) lost due to stroke with a relatively younger age of onset compared to the Western population. In India's public healthcare system, many stroke patients seek care at tertiary-level government-funded medical colleges where an optimal level of stroke care is expected. However, there are no studies from India that have assessed the quality of stroke care, including infrastructure, imaging facilities, or the availability of stroke care units in medical colleges. AIM This study aimed to understand the existing protocols and management of acute stroke care across 22 medical colleges in India, as part of the baseline assessment of the ongoing IMPETUS stroke study. METHODS A semi-structured quantitative pre-tested questionnaire, developed based on review of literature and expert discussion, was mailed to 22 participating sites of the IMPETUS stroke study. The questionnaire assessed comprehensively all components of stroke care, including human resources, emergency system, in-hospital care, and secondary prevention. A descriptive analysis of their status was undertaken. RESULTS In the emergency services, limited stroke helpline numbers, 3/22 (14%); prenotification system, 5/22 (23%); and stroke-trained physicians were available, 6/22 (27%). One-third of hospitals did not have on-call neurologists. Although non-contrast computed tomography (NCCT) was always available, 39% of hospitals were not doing computed tomography (CT) angiography and 13/22 (59%) were not doing magnetic resonance imaging (MRI) after routine working hours. Intravenous thrombolysis was being done in 20/22 (91%) hospitals, but 36% of hospitals did not provide it free of cost. Endovascular therapy was available only in 6/22 (27%) hospitals. The study highlighted the scarcity of multidisciplinary stroke teams, 8/22 (36%), and stroke units, 7/22 (32%). Lifesaving surgeries like hematoma evacuation, 11/22 (50%), and decompressive craniectomy, 9/22 (41%), were performed in limited numbers. The availability of occupational therapists, speech therapists, and cognitive rehabilitation was minimal. CONCLUSION This study highlighted the current status of acute stroke management in publicly funded tertiary care hospitals. Lack of prenotification, limited number of stroke-trained physicians and neurosurgeons, relatively lesser provision of free thrombolytic agents, limited stroke units, and lack of rehabilitation services are areas needing urgent attention by policymakers and creation of sustainable education models for uniform stroke care by medical professionals across the country.
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Affiliation(s)
- Manish Salunkhe
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Partha Haldar
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepshikha Prasad
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Shweta Gupta
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - M V Padma Srivastava
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Bhoi
- Department of Neurology, All India Institute of Medical Sciences, Bhubaneshwar, India
| | - Menka Jha
- Department of Neurology, All India Institute of Medical Sciences, Bhubaneshwar, India
| | - Priyanka Samal
- Department of Neurology, All India Institute of Medical Sciences, Bhubaneshwar, India
| | - Samhita Panda
- Department of Neurology, All India Institute of Medical Sciences, Jodhpur, India
| | - Sucharita Anand
- Department of Neurology, All India Institute of Medical Sciences, Jodhpur, India
| | - Niraj Kumar
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, India
| | - Ashutosh Tiwari
- Department of Neurology, All India Institute of Medical Sciences, Rishikesh, India
| | - S Gopi
- Department of Neurology, Andhra Medical College, Visakhapatnam, India
| | | | - Jyoti Garg
- Department of Neurology, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - M P S Chawla
- Department of Medicine, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India
| | - Biman Kanti Ray
- Department of Neurology, Bangur Institute of Neurology, Institute of Post Graduate Medical Education & Research (IPGMER), Kolkata, India
| | - Amit Bhardwaj
- Department of Neurology, Dr Rajendra Prasad Government Medical College, Tanda, India
| | - Alok Verma
- Department of Neurology, Ganesh Shankar Vidyarthi Memorial (GSVM) Medical College, Kanpur, India
| | - Nikhil Dongre
- Department of Neurology, Ganesh Shankar Vidyarthi Memorial (GSVM) Medical College, Kanpur, India
| | - Gurpreet Chhina
- Department of Medicine, Government Medical College, Amritsar, India
| | - Raminder Sibia
- Department of Medicine, Government Medical College, Patiala, India
| | | | - Paresh Zanzmera
- Department of Neurology, Government Medical College, Surat, India
| | - Thomas Iype
- Department of Neurology, Government Medical College, Trivandrum, India
| | - Sulena
- Department of Medicine, Guru Gobind Singh Medical College and Hospital, Faridkot, India
| | - Ravinder Garg
- Department of Medicine, Guru Gobind Singh Medical College and Hospital, Faridkot, India
| | - Ashok Kumar
- Department of Neurology, Indira Gandhi Institute of Medical Sciences, Patna, India
| | - Abhay Ranjan
- Department of Neurology, Indira Gandhi Institute of Medical Sciences, Patna, India
| | - Vijay Sardana
- Department of Neurology, Kota Medical College, Kota, India
| | | | - Bharat Bhushan
- Department of Neurology, Kota Medical College, Kota, India
| | - Alvee Saluja
- Department of Neurology, Lady Hardinge Medical College, New Delhi, India
| | - Pramod Darole
- Department of Medicine, Lokmanya Tilak Municipal Medical College and General Hospital, Mumbai, India
| | - Kiran Bala
- Department of Neurology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
| | - Surekha Dabla
- Department of Neurology, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
| | - Inder Puri
- Department of Neurology, Sardar Patel Medical College, Bikaner, India
| | - Shalin Shah
- Department of Neurology, Sardar Vallabhbhai Patel Institute of Medical Sciences and Research, Ahmedabad, India
| | | | - Smita Nath
- Department of Medicine, University College of Medical Sciences, Delhi, India
| | - Shishir Chandan
- Department of Neurology, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
| | - Rupali Malik
- Department of Medicine, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India
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Rossis C, Michail KA, Middleton N, Karanikola M, Papathanassoglou E, Mpouzika M. Knowledge on Stroke Recognition and Management among Emergency Department Healthcare Professionals in the Republic of Cyprus. Healthcare (Basel) 2023; 12:77. [PMID: 38200983 PMCID: PMC10778653 DOI: 10.3390/healthcare12010077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/20/2023] [Accepted: 12/25/2023] [Indexed: 01/12/2024] Open
Abstract
Stroke is a global leading cause of death and disability. Knowledge of related guidelines is crucial for emergency department (ED) staff, influencing early diagnosis and timely treatment. We investigated Greek Cypriot ED healthcare professionals' (nurses and physicians) knowledge in recognizing and managing stroke. A descriptive cross-sectional study spanned November 2019 to April 2020, encompassing four private and seven public EDs in the Republic of Cyprus. The data were collected through a self-reported questionnaire developed by the research team, consisting of 37 questions. Eight questions focused on sociodemographic and employment characteristics, twenty-eight assessed knowledge in stroke recognition and management (each item was equally weighted without deliberate prioritization), and one question addressed self-assessment of knowledge in stroke care. A total of 255 nurses (response rate (RR): 74.1%) and 26 physicians (RR: 47.3%) completed the questionnaire. The average correct response rate was 12.9 out of 28 statements (SD: 4.2), with nurses and physicians scoring 12.6 (SD: 4.1) and 15.7 (SD: 4), respectively. Work experience significantly influenced stroke knowledge, with all groups demonstrating superiority over those with less than one year of experience. Participants with previous training scored an average of 1.45 additional correct answers while educational attainment did not significantly influence stroke knowledge. Investigating stroke knowledge among emergency department nurses and physicians in the Republic of Cyprus revealed significant deficits. This study stresses targeted interventions, including education, yearly examinations, workshops with hands-on training, and repeated training, to address these gaps and enhance the overall stroke care capabilities of the healthcare professionals.
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Affiliation(s)
| | - Koralia A. Michail
- Department of Nursing, Cyprus University of Technology, 3041 Limassol, Cyprus; (K.A.M.); (N.M.); (M.K.)
| | - Nicos Middleton
- Department of Nursing, Cyprus University of Technology, 3041 Limassol, Cyprus; (K.A.M.); (N.M.); (M.K.)
| | - Maria Karanikola
- Department of Nursing, Cyprus University of Technology, 3041 Limassol, Cyprus; (K.A.M.); (N.M.); (M.K.)
| | | | - Meropi Mpouzika
- Department of Nursing, Cyprus University of Technology, 3041 Limassol, Cyprus; (K.A.M.); (N.M.); (M.K.)
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Feigin VL, Owolabi MO. Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission. Lancet Neurol 2023; 22:1160-1206. [PMID: 37827183 PMCID: PMC10715732 DOI: 10.1016/s1474-4422(23)00277-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 40.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 07/14/2023] [Indexed: 10/14/2023]
Abstract
Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met. In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. Disability-adjusted life-years (DALYs) The sum of the years of life lost as a result of premature mortality from a disease and the years lived with a disability associated with prevalent cases of the disease in a population. One DALY represents the loss of the equivalent of one year of full health On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases. Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders. The Lancet Group takes a neutral position with respect to territorial claims in published maps and institutional affiliations.
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Affiliation(s)
- Valery L Feigin
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Sciences, Auckland University of Technology, Auckland, New Zealand.
| | - Mayowa O Owolabi
- Centre for Genomics and Precision Medicine, College of Medicine, University of Ibadan, Ibadan, Nigeria; University College Hospital, Ibadan, Nigeria; Blossom Specialist Medical Centre, Ibadan, Nigeria.
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5
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Opare-Addo PA, Oppong C, Gyamfi RA, Aikins M, Nsohlebna Nsoh L, Asare-Bediako S, Attafuah E, Sarfo K, Sampah AK, Yiadom JB, Sarfo FS. Deciphering the contextual barriers to mainstreaming the implementation of stroke thrombolysis in a Ghanaian hospital: Findings from the activate mixed-methods study. J Stroke Cerebrovasc Dis 2023; 32:107394. [PMID: 37866294 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2023] [Revised: 09/20/2023] [Accepted: 09/25/2023] [Indexed: 10/24/2023] Open
Abstract
BACKGROUND Each year, stroke-related death and disability claim over 143 million years of healthy life globally. Despite accounting for much of the global stroke burden, acute stroke care in Low-and-Middle-Income Countries remains suboptimal. Thrombolysis, an effective treatment option for stroke, is only received by a minority of stroke patients in these settings. AIM To determine the context-specific barriers and facilitators for the implementation of mainstream stroke thrombolysis in a Ghanaian hospital. METHODS We employed a mixed-methods approach involving key stakeholders (recipients, providers, and leaders) in the acute stroke care continuum. Surveys were administered to acute stroke patients, and in-depth key informant interviews were conducted with experts in stroke care, including a neurologist, medical director, neurology residents, a stroke nurse, emergency physicians, a radiologist, and a pharmacist. The data collected from these interviews were transcribed and analysed using content analysis with the CFIR (Consolidated Framework for Implementation Research) model as a guiding template. Two independent coders were involved in the analysis process to ensure reliability and accuracy. RESULTS The stroke thrombolysis rate over a 6-month period was 0.83% (2 out of 242), with an average door-to-needle time among thrombolyzed patients being 2 hours, 37 minutes. Only 12.8% of patients (31 out of 242) presented within 4.5 hours of stroke symptom onset. The most significant obstacle to the implementation of acute stroke thrombolysis was related to the characteristics of the individuals involved, notably delays in presenting to the hospital among stroke patients due to a lack of knowledge about stroke symptoms and cultural beliefs. Additionally, a significant bottleneck that contributed to the discrepancy between the number of patients who presented within the 4.5-6 hour window and the number of patients who actually received thrombolysis was the inability to pay for the cost of thrombolytic agents. This was followed by challenges in the implementation processes. CONCLUSIONS Addressing challenges related to stroke awareness, and financial constraints via multi-level stakeholder engagement, and enactment of stroke protocols are crucial steps in ensuring a successful implementation of a stroke thrombolysis program in a resource-limited setting.
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Affiliation(s)
| | - Chris Oppong
- Komfo Anokye Teaching Hospital, Kumasi, Ghana; Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
| | | | | | | | | | | | - Kofi Sarfo
- Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | | | | | - Fred Stephen Sarfo
- Komfo Anokye Teaching Hospital, Kumasi, Ghana; Kwame Nkrumah University of Science & Technology, Kumasi, Ghana
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6
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Bencheikh N, Zarrintan S, Quatramoni JG, Al-Nouri O, Malas M, Gaffey AC. Vascular Surgery in Low-Income and Middle-Income Countries: A State-of-the-Art Review. Ann Vasc Surg 2023; 95:297-306. [PMID: 37285965 DOI: 10.1016/j.avsg.2023.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 05/15/2023] [Accepted: 05/19/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Cardiovascular disease (CVD) represents 32% of all global deaths. Studies have shown an increase in CVD prevalence and mortality with the most substantial increase in low-income and middle-income countries (LMICs). Within LMICs, we sought to 1) measure the burden of CVD with respect to aortic aneurysm (AA), ischemic stroke (IS), and peripheral arterial disease (PAD); 2) quantify surgical access to vascular surgery services; and 3) identify challenges and solutions to addressing disparities. METHODS The Institute for Health Metrics and Evaluation Global Burden of Disease Results Tool was used to assess the global burden of CVD (AA, PAD, IS). Population data were extracted from the World Bank & Workforce data. A literature review was completed through PubMed. RESULTS The number of deaths attributable to AA, PAD, and IS in LMICs increased by up to 102% between 1990 and 2019. Disability-adjusted life-years (DALYs) lost to AA, PAD, and IS in LMICs also increased by up to 67%. High-income countries (HIC) had a less considerable increase in deaths and DALYs during this time period. There are 101 and 72.7 vascular surgeons per 10 million people in the United States and United Kingdom, respectively. LMICs, such as Morocco, Iran, and South Africa have 10 times less this number. Ethiopia has 0.25 vascular surgeons per 10 million people, 400 times less than the United States. Interventions addressing these global disparities should address infrastructure and financing, data collection and sharing, patient knowledge and beliefs, and workforce development. CONCLUSIONS Extreme regional discrepancies are evidence at a global scale. Identifying mechanisms to expand the vascular surgical workforce to meet the increasing need for vascular surgical access is imminent.
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Affiliation(s)
- Nissma Bencheikh
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Sina Zarrintan
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | | | - Omar Al-Nouri
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Mahmoud Malas
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA
| | - Ann C Gaffey
- Division of Vascular & Endovascular Surgery, Department of Surgery, UC San Diego, San Diego, CA.
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Aderinto N, Olatunji D, Abdulbasit M, Edun M. The essential role of neuroimaging in diagnosing and managing cerebrovascular disease in Africa: a review. Ann Med 2023; 55:2251490. [PMID: 37643607 PMCID: PMC10496522 DOI: 10.1080/07853890.2023.2251490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 07/11/2023] [Accepted: 08/20/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Cerebrovascular disease is a significant cause of morbidity and mortality in Africa, and using neuroimaging techniques has improved the diagnosis and management of this disease. However, there is a lack of comprehensive reviews of the role and effectiveness of neuroimaging techniques in the African context. METHODS We reviewed the literature to evaluate the role of neuroimaging in diagnosing and managing cerebrovascular disease in Africa. Our search included electronic databases such as PubMed, Scopus, and Google Scholar from 2000 to April 2023. We included peer-reviewed studies written in English that reported on the use of neuroimaging in diagnosing and managing cerebrovascular disease in African populations. We excluded non-peer-reviewed articles, letters, editorials, and studies unrelated to cerebrovascular disease, neuroimaging, or Africa. A total of 102 potential articles were identified; after applying our exclusion criteria and removing duplicated articles, 51 articles were reviewed. RESULTS Our findings suggest that neuroimaging techniques such as CT, MRI, and Skull x-ray play a crucial role in diagnosing and managing cerebrovascular disease in Africa. CT and MRI were the most commonly used techniques, with CT being more widely available and less expensive than MRI. However, challenges to using neuroimaging in Africa include the high cost of equipment and maintenance, lack of trained personnel, and inadequate infrastructure. These challenges limit the widespread use of neuroimaging in diagnosing and managing cerebrovascular disease in Africa. CONCLUSION Neuroimaging techniques are essential for diagnosing and managing cerebrovascular disease in Africa, but challenges to their use must be addressed to improve healthcare outcomes. Our policy recommendations can help improve the availability and accessibility of neuroimaging services in Africa.
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Affiliation(s)
- Nicholas Aderinto
- Department of Medicine and Surgery, Ladoke Akintola University of Technology, Nigeria
| | - Deji Olatunji
- Department of Medicine and Surgery, University of Ilorin, Nigeria
| | - Muili Abdulbasit
- Department of Medicine and Surgery, Ladoke Akintola University of Technology, Nigeria
| | - Mariam Edun
- Department of Medicine and Surgery, University of Ilorin, Nigeria
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8
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Habibi J, Bosch J, Bidulka P, Belson S, DePaul V, Gandhi D, Kumurenzi A, Melifonwu R, Pandian J, Langhorne P, Solomon JM, Dawar D, Carroll S, Urimubenshi G, Kaddumukasa M, Hamilton L. Strategies for specialty training of healthcare professionals in low-resource settings: a systematic review on evidence from stroke care. BMC MEDICAL EDUCATION 2023; 23:442. [PMID: 37328888 PMCID: PMC10273731 DOI: 10.1186/s12909-023-04431-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 06/06/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND The greatest mortality and disability from stroke occurs in low- and middle-income countries. A significant barrier to implementation of best stroke care practices in these settings is limited availability of specialized healthcare training. We conducted a systematic review to determine the most effective methods for the provision of speciality stroke care education for hospital-based healthcare professionals in low-resource settings. METHODS We followed the PRISMA guidelines for systematic reviews and searched PubMed, Web of Science and Scopus for original clinical research articles that described or evaluated stroke care education for hospital-based healthcare professionals in low-resource settings. Two reviewers screened titles/abstracts and then full text articles. Three reviewers critically appraised the articles selected for inclusion. RESULTS A total of 1,182 articles were identified and eight were eligible for inclusion in this review; three were randomized controlled trials, four were non-randomized studies, and one was a descriptive study. Most studies used several approaches to education. A "train-the-trainer" approach to education was found to have the most positive clinical outcomes (lower overall complications, lengths of stay in hospital, and clinical vascular events). When used for quality improvement, the "train-the-trainer" approach increased patient reception of eligible performance measures. When technology was used to provide stroke education there was an increased frequency in diagnosis of stroke and use of antithrombotic treatment, reduced door-to-needle times, and increased support for decision making in medication prescription was reported. Task-shifting workshops for non-neurologists improved knowledge of stroke and patient care. Multidimensional education demonstrated an overall care quality improvement and increased prescriptions for evidence-based therapies, although, there were no significant differences in secondary prevention efforts, stroke reoccurrence or mortality rates. CONCLUSIONS The "train the trainer" approach is likely the most effective strategy for specialist stroke education, while technology is also useful if resources are available to support its development and use. If resources are limited, basic knowledge education should be considered at a minimum and multidimensional training may not be as beneficial. Research into communities of practice, led by those in similar settings, may be helpful to develop educational initiatives with relevance to local contexts.
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Affiliation(s)
- Junaid Habibi
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada.
| | - Jackie Bosch
- Population Health Research Institute, Hamilton, ON, Canada
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Patrick Bidulka
- London School of Hygiene and Tropical Medicine, London, England, UK
| | | | - Vincent DePaul
- School of Rehabilitation Therapy, Queen's University, Kingston, ON, Canada
| | - Dorcas Gandhi
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Anne Kumurenzi
- Population Health Research Institute, Hamilton, ON, Canada
| | | | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Peter Langhorne
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
| | - John M Solomon
- Department of Physiotherapy, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Dimple Dawar
- Department of Neurology, Christian Medical College, Ludhiana, Punjab, India
| | - Sandra Carroll
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Gerard Urimubenshi
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Martin Kaddumukasa
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Leah Hamilton
- Population Health Research Institute, Hamilton, ON, Canada
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9
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Van Dusen RA, Abernethy K, Chaudhary N, Paudyal V, Kurmi O. Association of the COVID-19 pandemic on stroke admissions and treatment globally: a systematic review. BMJ Open 2023; 13:e062734. [PMID: 36931673 PMCID: PMC10030289 DOI: 10.1136/bmjopen-2022-062734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023] Open
Abstract
OBJECTIVES The COVID-19 pandemic has highlighted insufficiencies and gaps within healthcare systems globally. In most countries, including high-income countries, healthcare facilities were over-run and occupied with too few resources beyond capacity. We carried out a systematic review with a primary aim to identify the influence of the COVID-19 pandemic on the presentation and treatment of stroke globally in populations≥65 years of age. DESIGN A systematic review was completed. In total, 38 papers were included following full-text screening. DATA SOURCES PubMed, MEDLINE and Embase. ELIGIBILITY CRITERIA Eligible studies included observational and real-world evidence publications with a population who have experienced stroke treatment during the COVID-19 pandemic. Exclusion criteria included studies comparing the effect of the COVID-19 infection on stroke treatment and outcomes. DATA EXTRACTION AND SYNTHESIS Primary outcome measures extracted were the number of admissions, treatment times and patient outcome. Secondary outcomes were severity on admission, population risk factors and destination on discharge. No meta-analysis was performed. RESULTS This review demonstrated that 84% of studies reported decreased admissions rates during the COVID-19 pandemic. However, among those admitted, on average, had higher severity of stroke. Additionally, in-hospital stroke treatment pathways were affected by the implementation of COVID-19 protocols, which resulted in increased treatment times in 60% of studies and increased in-hospital mortality in 82% of studies by 100% on average. The prevalence of stroke subtype (ischaemic or haemorrhagic) and primary treatment methods (thrombectomy or thrombolysis) did not vary due to the COVID-19 pandemic. CONCLUSIONS During the COVID-19 pandemic, many populations hesitated to seek medical attention, decreasing hospital admissions for less severe strokes and increasing hospitalisation of more severe cases and mortality. The effect of the pandemic on society and healthcare systems needs to be addressed to improve stroke treatment pathways and prepare for potential future epidemics. PROSPERO REGISTRATION NUMBER CRD42021248564.
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Affiliation(s)
| | - Kiera Abernethy
- Physical and environmenal science, University of Toronto, Toronto, Ontario, Canada
| | | | - Vibhu Paudyal
- School of Pharmacy, University of Birmingham, Birmingham, UK
| | - Om Kurmi
- Global Health, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Faculty Centre for Intelligent Healthcare, Coventry University, Coventry, UK
- Division of Respirology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Nexus Institute of Research and Innovation, Lalitpur, Nepal
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10
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Tan MA, Layug EJV, Singh BP, Parakh M. Diagnosis of Pediatric Stroke in Resource Limited Settings. Semin Pediatr Neurol 2022; 44:100997. [PMID: 36456040 DOI: 10.1016/j.spen.2022.100997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 10/14/2022]
Abstract
Global awareness of stroke as a significant cause of neurologic sequelae and death in children has increased over the years as more data in this field becomes available. However, most published literature on pediatric stroke have limited geographic representation. Data on childhood stroke from developing countries remains limited. Thus, this paper reviewed geographic/ethnic differences in pediatric stroke risk factors highlighting those reported in low- and middle-income countries, and proposes a childhood arterial ischemic stroke diagnostic algorithm for resource limited settings. Stroke risk factors include cardiac disorders, infectious diseases, cerebral arteriopathies, hematologic disorders, inflammatory diseases, thrombophilia and genetic conditions. Infection of the central nervous system particularly tuberculous meningitis, is a leading cause of pediatric arterial ischemic stroke in developing countries. Stroke should be considered in children with acute focal neurologic deficit especially in the presence of aforementioned risk factors. Cranial magnetic resonance imaging with angiography is the neuroimaging modality of choice but if unavailable, cranial computed tomography with angiography may be performed as an alternative. If both are not available, transcranial doppler together with neurologic exam may be used to screen children for arterial ischemic stroke. Etiological diagnosis follows with the aid of appropriate laboratory tests that are available in each level of care. International collaborative research on stroke risk factors that are prevalent in low and middle income countries will provide information for drafting of stroke care guidelines that are universal yet inclusive taking into consideration regional differences in available resources with the goal of reducing global stroke burden.
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Affiliation(s)
- Marilyn A Tan
- Division of Pediatric Neurology, Departments of Pediatrics and Neurosciences, University of the Philippines - Philippine General Hospital, Manila, Philippines.
| | - Elbert John V Layug
- Division of Pediatric Neurology, Departments of Pediatrics and Neurosciences, University of the Philippines - Philippine General Hospital, Manila, Philippines
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11
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Mohammed T, Nyante GG, Mothabeng DJ. An evaluation of the structure and process of stroke rehabilitation in primary, secondary and tertiary hospitals in Ghana. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2022; 78:1637. [PMID: 35747516 PMCID: PMC9210176 DOI: 10.4102/sajp.v78i1.1637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/10/2022] [Indexed: 11/30/2022] Open
Abstract
Background Evidence shows that quality indicators such as the structure and process of stroke rehabilitation can influence patient outcomes. However, not much attention has been paid to the study of these issues in low- and middle-income countries such as Ghana. Objectives Our study evaluated the structure and process of stroke rehabilitation in primary, secondary and tertiary hospitals in the Greater Accra Region of Ghana. Method A cross-sectional survey was conducted involving 111 healthcare professionals. The World Health Organization (WHO) situational analysis and Measure of Processes of Care for Service Providers for Adults (MPOC-SP[A]) questionnaires were administered to gather information on the structure and process of stroke rehabilitation. Descriptive statistics were used to summarise data, and chi-square and Kruskal–Wallis tests were used to establish associations and comparisons, respectively. Results A stroke unit was only available in the tertiary hospital. Although all three hospitals had a multidisciplinary team approach to care, the constituents differed. Length of hospital-stay, duration of treatment and basis for discharge from acute care were not associated with the hospitals. Therapy sessions, access to computed tomography (CT) and magnetic resonance imaging (MRI) scanning were dependent on the hospitals. Conclusion The structure and process of stroke rehabilitation across the three hospitals were similar in some constructs and different in others. Clinical implications Data gathered will help to provide information on the available structure and processes of stroke rehabilitation, which could help assess the quality of care provided.
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Affiliation(s)
- Tawagidu Mohammed
- Department of Physiotherapy, School of Healthcare Sciences, University of Pretoria, Pretoria, South Africa
- Department of Physiotherapy, School of Biomedical and Allied Health Sciences, University of Ghana, Accra, Ghana
| | - Gifty G. Nyante
- Department of Physiotherapy, School of Biomedical and Allied Health Sciences, University of Ghana, Accra, Ghana
| | - Diphale J. Mothabeng
- Department of Physiotherapy, School of Healthcare Sciences, University of Pretoria, Pretoria, South Africa
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12
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Kumi F, Bugri AA, Adjei S, Duorinaa E, Aidoo M. Quality of acute ischemic stroke care at a tertiary Hospital in Ghana. BMC Neurol 2022; 22:28. [PMID: 35039001 PMCID: PMC8762857 DOI: 10.1186/s12883-021-02542-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/21/2021] [Indexed: 11/10/2022] Open
Abstract
Background Information on the quality of acute ischemic stroke care provided in lower-to-middle income countries is limited. Objective This study was undertaken to examine the quality of acute ischemic stroke care provided at Tamale Teaching Hospital in Ghana. Methods The medical records of patients admitted into the medical ward of the hospital between January to October 2021 were reviewed retrospectively. Extent of compliance to 15 stroke performance indicators were determined. Results Under the study period, 105 patients were admitted at the hospital with acute ischemic stroke. The mean (±SD) age was 65 ± 12 years; 38.1% were males; 65.7% had National Health Insurance Scheme coverage. Glasgow Coma Scale was the only functional stroke rating scale used by physicians to rate stroke severity. About a quarter of the patients had CT scan performed within 24 h of admission. Less than a quarter of the patients had a last known well time documented. Rate of thrombolytic administration was 0%. Less than a quarter of the patients were prescribed venous thromboembolism prophylaxis on the day of admission or day after. Only 13.8% of patients had documented reasons for not being prescribed venous thromboembolism prophylaxis. Antiplatelet therapy was prescribed to 33.3% of the patients by the end of day 2 of admission. Anticoagulation was prescribed to all patients who had comorbid condition of atrial fibrillation as part of the discharge medications. More than half of the patients were discharged to go home with statin medications. Documented stroke education was provided to 31.4% caretakers or patients. Slightly less than half of the patients were assessed for or received rehabilitation. Less than a quarter had documented dysphagia screening within 24 h of admission. None of the patient had their stroke severity rated with National Institutes of Health Stroke Scale on arrival. No patient obtained carotid imaging assessment by end of day 2. Conclusion There were several gaps in the quality of acute ischemic stroke care provided to patients at the Tamale Teaching Hospital. With the exception of discharging patients on statin medications, there was poor adherence to all other stroke performance indicators.
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Affiliation(s)
- Frank Kumi
- Pharmacy Unit, King's Medical Center, Tamale, Ghana.
| | - Amos A Bugri
- Pharmacy Directorate, Tamale Teaching Hospital, Tamale, Ghana
| | - Stephen Adjei
- Pharmacy Directorate, Tamale Teaching Hospital, Tamale, Ghana
| | - Elvis Duorinaa
- Pharmacy Directorate, Tamale Teaching Hospital, Tamale, Ghana
| | - Matthew Aidoo
- Department of Pharmacology, University for Development Studies, Tamale, Ghana
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13
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Roushdy T, Aref H, Kesraoui S, Temgoua M, Nono KP, Gebrewold MA, Peter W, Gopaul U, Belahsen MF, Ben-Adji D, Melifonwu R, Pugazhendhi S, Woodcock N, Mohamed MH, Rossouw A, Matuja S, Ruanda MK, Mhiri C, Saylor D, Nahas NE, Shokri H. Stroke services in Africa: What is there and what is needed. Int J Stroke 2022; 17:972-982. [PMID: 35034522 DOI: 10.1177/17474930211066416] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Over the past few years, the incidence and prevalence of stroke has been rising in most African countries and has been reported as one of the leading causes of morbidity and mortality. To study this problem, we need to realize the quality and availability of stroke care services as a priori to improve them. METHODS AND RESULTS In this study, we investigated the availability of different stroke-related services in 17 countries from different African regions. An online survey was conducted and fulfilled by stroke specialists and included primary prevention, acute management, diagnostic tools, medications, postdischarge services, and stroke registries. The results showed that although medications for secondary prevention are available, yet many other services are lacking in various countries. CONCLUSION This study displays the deficient aspects of stroke services in African countries as a preliminary step toward active corrective procedures for the improvement of stroke-related health services.
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Affiliation(s)
- Tamer Roushdy
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hany Aref
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Selma Kesraoui
- Department of Neurology, Blida Hospital University, Blida, Algeria
| | - Michael Temgoua
- Institute of Applied Neurosciences and Functional Rehabilitation, Bethesda Hospital, Yaoundè, Cameroon
| | - Kiatoko Ponte Nono
- Initiative Plus Hospital Center, Kinshasa, Democratic Republic of the Congo
| | | | - Waweru Peter
- Kenyatta University Teaching, Referral & Research Hospital, Nairobi, Kenya
| | - Urvashy Gopaul
- University of Mauritius, Moka, Mauritius.,KITE-University Health Network (UHN), Toronto, ON, Canada
| | - Mohammed Faouzi Belahsen
- Neurology Department, Hassan II University Hospital, Sidi Mohamed Ben Abdellah University, Fez, Morocco
| | | | - Rita Melifonwu
- Stroke Rehabilitation, Stroke Action Nigeria, Abuja, Nigeria
| | | | | | | | | | - Sarah Matuja
- Department of Internal Medicine, Bugando Medical Centre/Catholic University of Health and Allied Sciences, Mwanza, Tanzania
| | - Mark Koba Ruanda
- Emergency Medicine Department, Mnazi Mmoja Hospital, Zanzibar, Tanzania
| | - Chokri Mhiri
- Department of Neurology, Habib Bourguiba University Hospital, Sfax, Tunisia
| | - Deanna Saylor
- Department of Medicine, University Teaching Hospital, Lusaka, Zambia.,Department of Neurology, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Nevine El Nahas
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Hossam Shokri
- Neurology Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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14
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Osuegbu OI, Adeniji FO, Owhonda GC, Kanee RB, Aigbogun EO. Exploring the Essential Stroke Care Structures in Tertiary Healthcare Facilities in Rivers State, Nigeria. INQUIRY : A JOURNAL OF MEDICAL CARE ORGANIZATION, PROVISION AND FINANCING 2022; 59:469580211067939. [PMID: 35049398 PMCID: PMC8785286 DOI: 10.1177/00469580211067939] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This study evaluated the essential stroke care structure available in the two Tertiary Health Facilities in Rives State, Nigeria. This was a descriptive survey involving the Stroke Care Survey and Assessment Tool (checklist/questionnaire) developed by the World Stroke Organisation to obtain information about the available essential stroke care structure (facilities, equipment, personnel and management protocol) at the two tertiary health facilities (RSUTH & UPTH). The study gathered relevant information, which was summarised into tables and graphs using Microsoft Excel 2016. From the results, although facilities had A and E departments, dedicated stroke units (fixed or mobile) were unavailable, and there was no locally developed protocol to support rapid triage of stroke patients. The facilities and equipment were either unavailable or insufficient. Only one health facility (RSUTH) provided 24 hrs/7 days laboratory services. The workforces were a mix between regular clinical staff and some specialists. Tissue plasminogen activator (tPA) use was non-existent, though specialists were trained on its administration. There was no locally developed or adopted stroke-specific clinical guidelines. In conclusion, the structural services available for stroke care within the studied tertiary health facilities were poor, unavailable or grossly insufficient. The state facility (RSUTH) suffered the most in terms of unavailable national support and staff development.
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Affiliation(s)
- Osborne Ikechuckwu Osuegbu
- Department of Preventive and Social Medicine, Faculty of Clinical Sciences, College of Health Sciences, 327041University of Port Harcourt, Choba, Nigeria
| | - Foluke Olukemi Adeniji
- Department of Preventive and Social Medicine, Faculty of Clinical Sciences, College of Health Sciences, 327041University of Port Harcourt, Choba, Nigeria
| | | | - Rogers Bariture Kanee
- Institute of Geo-Science and Space Technology, 108005Rivers State University, Oroworukwo, Nigeria
| | - Eric Osamudiamwen Aigbogun
- Department of Public Health, Faculty of Sciences and Technology, 248428Cavendish University Uganda, Kampala, Uganda
- Center for Occupational Health and Safety, Institute of Petroleum Studies, 327041University of Port Harcourt, Choba, Nigeria
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15
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Pandian JD, Kalkonde Y, Sebastian IA, Felix C, Urimubenshi G, Bosch J. Stroke systems of care in low-income and middle-income countries: challenges and opportunities. Lancet 2020; 396:1443-1451. [PMID: 33129395 DOI: 10.1016/s0140-6736(20)31374-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 04/18/2020] [Accepted: 06/09/2020] [Indexed: 12/27/2022]
Abstract
The burden of stroke is higher in low-income and middle-income countries (LMICs) than in high-income countries and is rising. Even though there are global policies and guidelines for implementing stroke care, there are many challenges in setting up stroke services in LMICs. Despite these challenges, there are many models of stroke care available in LMICs-eg, multidisciplinary team care led by a stroke neurologist, specialist-led care by neurologists, physician-led care, hub and spoke models incorporating stroke telemedicine (ie, telestroke), and task sharing involving community health workers. Alternative strategies have been developed, such as reorganising the existing hospital infrastructure by training health professionals to implement protocol-driven care. The future challenge is to identify what elements of organised stroke care can be implemented to make the largest gain. Simple interventions such as swallowing assessments, bowel and bladder care, mobility assessments, and consistent secondary prevention can prove to be key elements to improving post-discharge morbidity and mortality in LMICs.
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Affiliation(s)
- Jeyaraj D Pandian
- Department of Neurology, Christian Medical College, Ludhiana, India.
| | | | | | - Cynthia Felix
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gerard Urimubenshi
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda; Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jackie Bosch
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
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16
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Toma G, Essuman A, Fetters MD. Family medicine residency training in Ghana after 20 years: resident attitudes about their education. Fam Med Community Health 2020; 8:fmch-2020-000394. [PMID: 33093166 PMCID: PMC7583799 DOI: 10.1136/fmch-2020-000394] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective In addition to assessing educational needs of family medicine trainees in Ghana, we sought to assess whether those entering the training programme aimed to pursue an academic career. Design A case study using an anonymous cross-sectional survey through collaboration between faculty members from the family medicine departments of Ghana and the University of Michigan. Setting The family medicine postgraduate trainees and the most recent graduates in the three training sites, Accra, Kumasi and Mampong, as well as modular residents in Ghana served as the targeted participants during data collection between October and November of 2018. Participants Second and third year family medicine residents, fellows (known as senior residents in Ghana) and recent graduates were invited to participate in this study. Thirty-five of 77 eligible subjects provided responses (46% response rate), but five records were eliminated due to incomplete data to yield a survey completion rate of 39% (30/77). Result Participants were mostly men (n=19), and the average age of respondents was 37 years old. The participants indicated the residency programmes needed more faculty 97% (n=29), supervision during outpatient care 87% (n=26) and lectures 83% (n=25). The main reason provided by respondents for entering residency programme in family medicine, which is currently not required for practising primary care in Ghana, was to obtain more education 93% (n=28). Participants who had completed the residency programme were much more likely to be interested in becoming faculty compared with those still in residency (p <0.001). Conclusion The research confirms the need for more faculty and the importance of investing in faculty development resources for ensuring a robust programme. These findings provide constructive feedback that could improve residency curricula of the local and regional family medicine training programmes and supports investing in trainees and new graduates as future faculty candidates.
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Affiliation(s)
- Ghazwan Toma
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Akye Essuman
- Family Medicine Unit, Department of Community Health, University of Ghana, Accra, Ghana
| | - Michael D Fetters
- Department of Family Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Mixed Methods Program, University of Michigan, Ann Arbor, Michigan, USA
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17
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van Niekerk SM, Inglis-Jassiem G, Kamalakannan S, Fernandes S, Webster J, English R, Smythe T, Louw QA. Achieving universal health coverage for people with stroke in South Africa: protocol for a scoping review. BMJ Open 2020; 10:e041221. [PMID: 33046479 PMCID: PMC7552861 DOI: 10.1136/bmjopen-2020-041221] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 09/08/2020] [Accepted: 09/09/2020] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Stroke is the second most common cause of death after HIV/AIDS and a significant health burden in South Africa. The extent to which universal health coverage (UHC) is achieved for people with stroke in South Africa is unknown. Therefore, a scoping review to explore the opportunities and challenges within the South African health system to facilitate the achievement of UHC for people with stroke is warranted. METHODS AND ANALYSIS The scoping review will follow the approach recommended by Levac, Colquhoun and O'Brien, which includes five steps: (1) identifying the research question, (2) identifying relevant studies, (3) selecting the studies, (4) charting the data, and (5) collating, summarising and reporting the results. Health Systems Dynamics Framework and WHO Framework on integrated people-centred health services will be used to map, synthesise and analyse data thematically. ETHICS AND DISSEMINATION Ethical approval is not required for this scoping review, as it will only include published and publicly available data. The findings of this review will be published in an open-access, peer-reviewed journal and we will develop an accessible summary of the results for website posting and stakeholder meetings.
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Affiliation(s)
- Sjan-Mari van Niekerk
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Cape Town, South Africa
| | - Gakeemah Inglis-Jassiem
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Cape Town, South Africa
| | - Sureshkumar Kamalakannan
- SACDIR, Public Health Foundation of India, Gurgaon, India
- International Center for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Silke Fernandes
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Jayne Webster
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, Stellenbosch University, Cape Town, South Africa
| | - Rene English
- Division of Health Systems and Public Health, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, London, UK
| | - Tracey Smythe
- International Center for Evidence in Disability, London School of Hygiene and Tropical Medicine, London, UK
| | - Q A Louw
- Division of Physiotherapy, Department of Health and Rehabilitation Sciences, Stellenbosch University, Cape Town, South Africa
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18
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Baatiema L, Abimbola S, de-Graft Aikins A, Damasceno A, Kengne AP, Sarfo FS, Charway-Felli A, Somerset S. Towards evidence-based policies to strengthen acute stroke care in low-middle-income countries. J Neurol Sci 2020; 418:117117. [PMID: 32919367 DOI: 10.1016/j.jns.2020.117117] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 12/31/2022]
Abstract
Stroke is a major public health issue in many low- and middle-income countries (LMICs). Despite the emergence of new effective interventions for acute stroke care, uptake remains slow and largely inaccessible to patients in LMICs, where health systems response has been inadequate. In this paper, we propose a policy framework to optimise access to acute stroke care in LMICs. We draw on evidence from relevant primary studies, such as availability of evidence-based acute stroke care interventions, barriers to uptake of interventions for stroke care and insights on stroke mortality and morbidity burden in LMICs. Insights from review of secondary studies, principally systematic reviews on evidence-based acute stroke care; and the accounts and experiences of some regional experts on stroke and other NCDs have been taken into consideration. In LMICs, there is limited availability and access to emergency medical transport services, brain imaging services and best practice interventions for acute stroke care. Availability of specialist acute stroke workforce and low awareness of early stroke signs and symptoms are also major challenges impeding the delivery of quality stroke care services. As a result, stroke care in LMICs is patchy, fragmented and often results in poor patient outcomes. Reconfiguration of LMIC health systems is thus required to optimise access to quality acute stroke care. We therefore propose a ten-point framework to be adapted to country-specific health system capacity, needs and resources: Emergency medical transport and treatment services, scaling-up interventions and services for acute stroke care, clinical guidelines for acute stroke treatment and management, access to brain imaging services, human resource capacity development strategies, centralisation of stroke services, tele-stroke care, public awareness campaigns on early stroke symptoms, establish stroke registers and financing of stroke care in LMICs. While we recognise the challenges of implementing the recommendations in low resource settings, this list can provide a platform as well serve as the starting point for advocacy and prioritisation of interventions depending on context.
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Affiliation(s)
- Leonard Baatiema
- Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana.
| | - Seye Abimbola
- School of Public Health, University of Sydney, Australia.
| | | | | | - Andre Pascal Kengne
- Non-Communicable Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa.
| | - Fred S Sarfo
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana; Komfo Anokye Teaching Hospital, Department of Medicine, Kumasi, Ghana.
| | | | - Shawn Somerset
- Faculty of Health, University of Canberra, Canberra, Australia.
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19
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Srivastava MP, Bhatia R, Vishnu VY, Goyal M. Essential Workflow and Performance Measures for Optimizing Acute Ischemic Stroke Treatment in India. Stroke 2020; 51:1969-1977. [DOI: 10.1161/strokeaha.119.026733] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- M.V. Padma Srivastava
- Head of Department (Neurology), All India Institute of Medical Sciences (AIIMS), New Delhi (M.V.P.S.)
| | | | | | - Mayank Goyal
- Department of Radiology, Seaman Family MR Research Centre, Foothills Medical Centre, Calgary, Canada (M.G.)
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20
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Baatiema L, de-Graft Aikins A, Sarfo FS, Abimbola S, Ganle JK, Somerset S. Improving the quality of care for people who had a stroke in a low-/middle-income country: A qualitative analysis of health-care professionals' perspectives. Health Expect 2020; 23:450-460. [PMID: 31967387 PMCID: PMC7104640 DOI: 10.1111/hex.13027] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/06/2019] [Accepted: 12/27/2019] [Indexed: 01/08/2023] Open
Abstract
Background and Objective Efforts to improve the adoption of evidence‐based interventions for optimal patient outcomes in low‐/middle‐income countries (LMICs) are persistently hampered by a plethora of barriers. Yet, little is known about strategies to address such barriers to improve quality stroke care. This study seeks to explore health professionals’ views on strategies to improve quality stroke care for people who had a stroke in a LMIC. Methods A qualitative interview study design was adopted. A semi‐structured interview guide was used to conduct in‐depth interviews among forty stroke care providers in major referral centres in Ghana. Participants were from nursing, medical, specialist and allied health professional groups. A purposive sample was recruited to share their views on practical strategies to improve quality stroke care in clinical settings. A thematic analysis approach was utilized to inductively analyse the data. Results A number of overarching themes of strategies to improve quality stroke care were identified: computerization and digitization of medical practice, allocation of adequate resources, increase the human resource capacity to deliver stroke care, development of clinical guideline/treatment protocols, institutionalization of multidisciplinary care and professional development opportunities. These strategies were however differentially prioritized among different categories of stroke care providers. Conclusion Closing the gap between existing knowledge on how to improve quality of stroke care in LMICs has the potential to be successful if unique and context‐specific measures from the views of stroke care providers are considered in developing quality improvement strategies and health systems and policy reforms. However, for optimal outcomes, further research into the effectiveness and feasibility of the proposed strategies by stroke care providers is needed.
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Affiliation(s)
- Leonard Baatiema
- Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana
| | | | - Fred S Sarfo
- Kwame Nkrumah University of Science & Technology, Kumasi, Ghana.,Department of Medicine, Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Seye Abimbola
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - John K Ganle
- School of Public Health, University of Ghana, Legon, Ghana
| | - Shawn Somerset
- Faculty of Health, University of Canberra, Canberra, ACT, Australia
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Gadama Y, Kamtchum-Tatuene J, Benjamin L, Phiri T, Mwandumba HC. The significant gap between international standards and stroke management practices at Queen Elizabeth Central Hospital (Malawi): An audit report. Malawi Med J 2019; 31:249-255. [PMID: 32128035 PMCID: PMC7036432 DOI: 10.4314/mmj.v31i4.6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background The Queen Elizabeth Central Hospital (QECH) is preparing to set up the first stroke unit in Blantyre, Malawi. We conducted this audit to assess current stroke management practices and outcomes at QECH and identify priority areas for intervention. Methods From April to June 2018, we prospectively enrolled patients with acute stroke and collected data on clinical presentation, cardiovascular risk factors, investigations and interventions, in-hospital outcomes, and follow-up plans after discharge. The American Heart Association/American Stroke Association (AHA/ASA) guidelines were used as the standard of care for comparison. Results Fifty patients with acute stroke were enrolled (46% women, 54% men). The mean age was 63.1 years (95% CI: 59.7-66.6). The diagnosis of stroke was based on the World Health Organization criteria. The diagnosis was made within 24 hours of admission in 19 patients (38%). Acute revascularisation therapy was not available. Forty-eight patients (96%) had their vital signs checked at baseline and <10% had their vital signs checked more than three times within the first 24 hours. Essential blood tests including random blood sugar (RBS), full blood count (FBC), urea/creatinine, and lipid profiles were performed in 72%, 68%, 48%, and 4%, respectively. An electrocardiogram was performed on 34 patients (68%). Blood pressure on admission was >140/90 mmHg in 34 patients (68%), including 4 with values >220/120 mmHg. Nine patients had an RBS >10 mmol/L and four received insulin. Prophylaxis for deep venous thrombosis was offered to 12 patients (24%). Aspiration pneumonia was reported in 16 patients (32%) and was the most common hospital complication. The mean duration of hospitalisation was 10.4 days (95% CI: 5.6-15.2), and case fatality was 18%. The modified Rankin scale at discharge was ≤2 in 32% of patients. Only four patients (8%) were transferred to a rehabilitation centre. At the time of discharge, only 32% of patients received education on stroke. Conclusion Acute stroke care is less than optimal in this setting. Simple interventions such as reducing the delay in making a stroke diagnosis, early swallow assessments, and closer monitoring of vital signs could make a significant difference in stroke outcome. Furthermore, treating cardiovascular risk factors and setting up health education programmes to improve secondary prevention represent key priorities.
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Affiliation(s)
- Yohane Gadama
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, P.O. Box 30096, Chichiri, Blantyre 3, Malawi
- Institute of Neurology, University College London, London, UK
| | - Joseph Kamtchum-Tatuene
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, P.O. Box 30096, Chichiri, Blantyre 3, Malawi
- Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Laura Benjamin
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, P.O. Box 30096, Chichiri, Blantyre 3, Malawi
- Institute of Neurology, University College London, London, UK
- Institute of Infection and Global Health, University of Liverpool, UK
| | - Tamara Phiri
- Department of Medicine, Queen Elizabeth Central Hospital, P.O. Box 95, Blantyre, Malawi
| | - Henry C Mwandumba
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, College of Medicine, P.O. Box 30096, Chichiri, Blantyre 3, Malawi
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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22
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Chimatiro GL, Rhoda AJ. Scoping review of acute stroke care management and rehabilitation in low and middle-income countries. BMC Health Serv Res 2019; 19:789. [PMID: 31684935 PMCID: PMC6829977 DOI: 10.1186/s12913-019-4654-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 10/17/2019] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Stroke is a major public health concern, affecting millions of people worldwide. Care of the condition however, remain inconsistent in developing countries. The purpose of this scoping review was to document evidence of stroke care and service delivery in low and middle-income countries to better inform development of a context-fit stroke model of care. METHODS An interpretative scoping literature review based on Arksey and O'Malley's five-stage-process was executed. The following databases searched for literature published between 2010 and 2017; Cochrane Library, Credo Reference, Health Source: Nursing/Academic Edition, Science Direct, BioMed Central, Cumulative Index to Nursing and Allied Health Literature (CINNAHL), Academic Search Complete, and Google Scholar. Single combined search terms included acute stroke, stroke care, stroke rehabilitation, developing countries, low and middle-income countries. RESULTS A total of 177 references were identified. Twenty of them, published between 2010 and 2017, were included in the review. Applying the Donebedian Model of quality of care, seven dimensions of stroke-care structure, six dimensions of stroke care processes, and six dimensions of stroke care outcomes were identified. Structure of stroke care included availability of a stroke unit, an accident and emergency department, a multidisciplinary team, stroke specialists, neuroimaging, medication, and health care policies. Stroke care processes that emerged were assessment and diagnosis, referrals, intravenous thrombolysis, rehabilitation, and primary and secondary prevention strategies. Stroke-care outcomes included quality of stroke-care practice, functional independence level, length of stay, mortality, living at home, and institutionalization. CONCLUSIONS There is lack of uniformity in the way stroke care is advanced in low and middle-income countries. This is reflected in the unsatisfactory stroke care structure, processes, and outcomes. There is a need for stroke care settings to adopt quality improvement strategies. Health ministry and governments need to decisively face stroke burden by setting policies that advance improved care of patients with stroke. Stroke Units and Recombinant Tissue Plasminogen Activator (rtPA) administration could be considered as both a structural and process necessity towards improvement of outcomes of patients with stroke in the LMICs.
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Affiliation(s)
- George Lameck Chimatiro
- University of the Western Cape, Cape Town, South Africa
- Medical Rehabilitation College, Box 256, Blantyre, Malawi
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23
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Chimatiro GL, Rhoda AJ. The challenge to providing stroke care and rehabilitation in Malawi. JOURNAL OF GLOBAL HEALTH REPORTS 2019. [DOI: 10.29392/joghr.3.e2019049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
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Sanuade O. Understanding the cultural meanings of stroke in the Ghanaian setting: A qualitative study exploring the perspectives of local community residents. Wellcome Open Res 2018; 3:87. [PMID: 30569019 PMCID: PMC6290971 DOI: 10.12688/wellcomeopenres.14674.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2018] [Indexed: 12/03/2022] Open
Abstract
Background: Stroke has undergone different medical constructions over the years. While the medical profession posits that disease is a biological condition, universal and unchanging, social constructionists perceive illness as the social meaning of the biological condition. Even though the medical notion of stroke is monolithic and sometimes contradicts the representations by local community residents, little attention has been paid to understanding the cultural meanings of stroke. This study explores the cultural meanings of stroke in five different cultural settings across Ghana. Methods: 30 focus group discussions (FGDs) were conducted with local community members in five communities (Ga Mashie, Tafo, Gyegyeano, Chanshegu and Agorve) located in five regions in Ghana. The FGDs were conducted in Ga, Twi, Fante, Ewe and Dagbani, and were transcribed verbatim into English. The transcripts were analysed thematically. Results: The local words used for stroke in all the five cultural settings focused on physical disability associated with stroke after its onset, and this formed the dominant source of fear about the condition. Participants mentioned that spiritual and left-side stroke have the most debilitating impact on the sufferer. Although there was a general consensus that anyone can be at risk of stroke, there was a gender dynamics in the explanation of risk relativity. Participants believed that stroke can be cured through early detection and treatment, use of herbal medicines, and availability of financial resources. Compared to other disabling conditions, the community residents perceived stroke to be more severe due to the multifaceted disabilities associated with the condition. Conclusions: This study showed that the social meanings of stroke in the five communities are multifaceted, and reflected co-existence of biomedical and cultural frameworks. The findings showed the need to pay good attention to the sociocultural context when developing interventions strategies on stroke prevention and control in Ghana.
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Affiliation(s)
- Olutobi Sanuade
- Institute of Advanced Studies, University College London, London, WC1E6BT, UK
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25
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Sanuade O. Understanding the cultural meanings of stroke in the Ghanaian setting: A qualitative study exploring the perspectives of local community residents. Wellcome Open Res 2018; 3:87. [PMID: 30569019 PMCID: PMC6290971 DOI: 10.12688/wellcomeopenres.14674.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2018] [Indexed: 04/06/2024] Open
Abstract
Background: Stroke has undergone different medical constructions over the years. While the medical profession posits that disease is a biological condition, universal and unchanging, social constructionists perceive illness as the social meaning of the biological condition. Even though the medical notion of stroke is monolithic and sometimes contradicts the representations by local community residents, little attention has been paid to understanding the cultural meanings of stroke. This study explores the cultural meanings of stroke in five different cultural settings in Ghana. Methods: 30 focus group discussions (FGDs) were conducted with local community members in five communities (Ga Mashie, Tafo, Gyegyeano, Chanshegu and Agorve) located in five regions in Ghana. The FGDs were conducted in Ga, Twi, Fante, Ewe and Dagbani, and were transcribed verbatim into English. The transcripts were analysed thematically. Results: The local words used for stroke in all the five cultural settings focused on physical disability associated with stroke after its onset, and this formed the dominant source of fear about the condition. Participants mentioned that spiritual and left-side stroke have the most debilitating impact on the sufferer. Although there was a general consensus that anyone can be at risk of stroke, there was a gender dynamics in the explanation of risk relativity. Participants believed that stroke can be cured through early detection and treatment, use of herbal medicines, and availability of financial resources. Compared to other disabling conditions, the community residents perceived stroke to be more severe due to its multifaceted disabilities. Conclusions: This study showed that the social meanings of stroke in the five communities are multifaceted, and reflected co-existence of biomedical and cultural frameworks. The findings showed the need to pay good attention to the sociocultural context when developing interventions strategies on stroke prevention and control.
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Affiliation(s)
- Olutobi Sanuade
- Institute of Advanced Studies, University College London, London, WC1E6BT, UK
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26
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Abstract
Background: Stroke is the second leading cause of death and adult-onset disability globally. Although its incidence is reducing in developed countries, low- and middle-income countries, especially African countries, are witnessing an increase in cases of stroke, leading to high morbidity and mortality. Evidently, a new paradigm is needed on the continent to tackle this growing burden of stroke in its preventative and treatment aspects. Aims and Objectives: The aim of this study was to determine the scope of stroke care services, where they exist, and their relationship with currently existing health systems. Methods: A detailed literature search was undertaken referring to PubMed and Google Scholar for articles from January 1960 to March 2018, using a range of search terms. Of 93 publications, 45 papers were shortlisted, and 21 reviewed articles on existing stroke services were included. Results: The literature on models of stroke services in Africa is sparse. We identified focused systems of care delivery in the hyperacute, acute, and rehabilitative phases of stroke in a few African countries. There is a continent-wide paucity of data on the organization of prehospital stroke services. Only 3 African countries (South Africa, Egypt, and Morocco) reported experiences on thrombolysis. Also, the uptake of dedicated stroke units appears limited across the continent. Encouragingly, there are large-scale secondary prevention models on the continent, mostly within the context of experimental research projects, albeit with promising results. We found only 1 article on the interventional aspects of stroke care in our review, and this was a single-center report. Conclusions: The literature on the organization of stroke services is sparse in Africa. Dedicated action at policy, population, community, and hospital-based levels is urgently needed toward the organization of stroke services to tame the burgeoning burden of stroke on the African continent.
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Affiliation(s)
- Rufus O. Akinyemi
- Neuroscience and Ageing Research Unit, Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Ibadan, Nigeria
- Neurology Unit, Department of Medicine, University College Hospital,Ibadan, Nigeria
- Division of Neurology, Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria
| | - Olaleye A. Adeniji
- Division of Neurology, Department of Internal Medicine, Federal Medical Centre, Abeokuta, Nigeria
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Akinyemi RO, Owolabi MO, Ihara M, Damasceno A, Ogunniyi A, Dotchin C, Paddick SM, Ogeng'o J, Walker R, Kalaria RN. Stroke, cerebrovascular diseases and vascular cognitive impairment in Africa. Brain Res Bull 2018; 145:97-108. [PMID: 29807146 DOI: 10.1016/j.brainresbull.2018.05.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/20/2018] [Accepted: 05/22/2018] [Indexed: 12/30/2022]
Abstract
With increased numbers of older people a higher burden of neurological disorders worldwide is predicted. Stroke and other cerebrovascular diseases do not necessarily present with different phenotypes in Africa but their incidence is rising in tandem with the demographic change in the population. Age remains the strongest irreversible risk factor for stroke and cognitive impairment. Modifiable factors relating to vascular disease risk, diet, lifestyle, physical activity and psychosocial status play a key role in shaping the current spate of stroke related diseases in Africa. Hypertension is the strongest modifiable risk factor for stroke but is also likely associated with co-inheritance of genetic traits among Africans. Somewhat different from high-income countries, strokes attributed to cerebral small vessel disease (SVD) are higher >30% among sub-Saharan Africans. Raised blood pressure may explain most of the incidence of SVD-related strokes but there are likely other contributing factors including dyslipidaemia and diabetes in some sectors of Africa. However, atherosclerotic and cardioembolic diseases combined also appear to be common subtypes as causes of strokes. Significant proportions of cerebrovascular diseases are ascribed to various forms of infectious disease including complications of human immunodeficiency virus. Cerebral SVD leads to several clinical manifestations including gait disturbance, autonomic dysfunction and depression. Pathological processes are characterized by arteriolosclerosis, lacunar infarcts, perivascular spaces, microinfarcts and diffuse white matter changes, which can now all be detected on neuroimaging. Except for isolated cases of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy or CADASIL, hereditary arteriopathies have so far not been reported in Africa. Prevalence estimates of vascular dementia (2-3%), delayed dementia after stroke (10-20%) and vascular cognitive impairment (30-40%) do not appear to be vastly different from those in other parts of the world. However, given the current demographic transition in both urban and rural settings these figures will likely rise. Wider application of neuroimaging modalities and implementation of stroke care in Africa will enable better estimates of SVD and other subtypes of stroke. Stroke survivors with SVD type pathology are likely to have low mortality and therefore portend increased incidence of dementia.
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Affiliation(s)
- Rufus O Akinyemi
- Institute for Advanced Medical Research and Training, College of Medicine, University of Ibadan, Nigeria; Department of Medicine, College of Medicine, University of Ibadan, Nigeria
| | - Mayowa O Owolabi
- Department of Medicine, College of Medicine, University of Ibadan, Nigeria
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan
| | | | - Adesola Ogunniyi
- Department of Medicine, College of Medicine, University of Ibadan, Nigeria
| | - Catherine Dotchin
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, United Kingdom
| | - Stella-Maria Paddick
- Institute of Neuroscience, Newcastle University, Campus for Ageing & Vitality, Newcastle upon Tyne NE4 5PL, United Kingdom
| | - Julius Ogeng'o
- Department of Human Anatomy, University of Nairobi, Nairobi, Kenya
| | - Richard Walker
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, NE2 4AX, United Kingdom
| | - Raj N Kalaria
- Institute of Neuroscience, Newcastle University, Campus for Ageing & Vitality, Newcastle upon Tyne NE4 5PL, United Kingdom.
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Urimubenshi G, Cadilhac DA, Kagwiza JN, Wu O, Langhorne P. Stroke care in Africa: A systematic review of the literature. Int J Stroke 2018; 13:797-805. [DOI: 10.1177/1747493018772747] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Appropriate systems of stroke care are important to manage the increasing death and disability associated with stroke in Africa. Information on existing stroke services in African countries is limited. Aim To describe the status of stroke care in Africa. Summary of review We undertook a systematic search of the published literature to identify recent (1 January 2006–20 June 2017) publications that described stroke care in any African country. Our initial search yielded 838 potential papers, of which 38 publications were eligible representing 14/54 African countries. Across the publications included for our review, the proportion of stroke patients reported to arrive at hospital within 3 h from stroke onset varied between 10% and 43%. The median time interval between stroke onset and hospital admission was 31 h. Poor awareness of stroke signs and symptoms, shortages of medical transportation, health care personnel, and stroke units, and the high cost of brain imaging, thrombolysis, and outpatient physiotherapy rehabilitation services were reported as major barriers to providing best-practice stroke care in Africa. Conclusions This review provides an overview of stroke care in Africa, and highlights the paucity of available data. Stroke care in Africa usually fell below the recommended standards with variations across countries and settings. Combined efforts from policy makers and health care professionals in Africa are needed to improve, and ensure access, to organized stroke care in as many settings as possible. Mechanisms to routinely monitor usual care (i.e., registries or audits) are also needed to inform policy and practice.
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Affiliation(s)
- Gerard Urimubenshi
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Dominique A Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Melbourne, Clayton, Australia
- Stroke Division, The Florey Institute Neuroscience and Mental Health, Heidelberg, University of Melbourne, Melbourne, Victoria, Australia
| | - Jeanne N Kagwiza
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Peter Langhorne
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Baatiema L, Chan CKY, Sav A, Somerset S. Interventions for acute stroke management in Africa: a systematic review of the evidence. Syst Rev 2017; 6:213. [PMID: 29065915 PMCID: PMC5655819 DOI: 10.1186/s13643-017-0594-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 10/02/2017] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND The past decades have witnessed a rapid evolution of research on evidence-based acute stroke care interventions worldwide. Nonetheless, the evidence-to-practice gap in acute stroke care remains variable with slow and inconsistent uptake in low-middle income countries (LMICs). This review aims to identify and compare evidence-based acute stroke management interventions with alternative care on overall patient mortality and morbidity outcomes, functional independence, and length of hospital stay across Africa. METHODS This review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. An electronic search was conducted in six databases comprising MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Academic Search Complete and Cochrane Library for experimental and non-experimental studies. Eligible studies were abstracted into evidence tables and their methodological quality appraised using the Joanna Briggs Institute checklist. Data were analysed and presented narratively with reference to observed differences in patient outcomes, reporting p values and confidence intervals for any possible relationship. RESULTS Initially, 1896 articles were identified and 37 fully screened. Four non-experimental studies (three cohort and one case series studies) were included in the final review. One study focused on the clinical efficacy of a stroke unit whilst the remaining three reported on thrombolytic therapy. The results demonstrated a reduction in patient deaths attributed to stroke unit care and thrombolytic therapy. Thrombolytic therapy was also associated with reductions in symptomatic intracerebral haemorrhage (SICH). However, the limited eligible studies and methodological limitations compromised definitive conclusions on the extent of and level of efficacy of evidence-based acute stroke care interventions across Africa. CONCLUSION Evidence from this review confirms the widespread assertion of low applicability and uptake of evidence-based acute stroke care in LMICs. Despite the limited eligible studies, the overall positive patient outcomes following such interventions demonstrate the applicability and value of evidence-based acute stroke care interventions in Africa. Health policy attention is thus required to ensure widespread applicability of such interventions for improved patients' outcomes. The review findings also emphasises the need for further research to unravel the reasons for low uptake. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42016051566.
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Affiliation(s)
- Leonard Baatiema
- Regional Institute for Population Studies, University of Ghana, Legon, Accra, Ghana. .,School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia.
| | - Carina K Y Chan
- School of Psychology, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
| | - Adem Sav
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
| | - Shawn Somerset
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
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Baatiema L, Otim ME, Mnatzaganian G, de-Graft Aikins A, Coombes J, Somerset S. Health professionals' views on the barriers and enablers to evidence-based practice for acute stroke care: a systematic review. Implement Sci 2017; 12:74. [PMID: 28583164 PMCID: PMC5460544 DOI: 10.1186/s13012-017-0599-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 05/08/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Adoption of contemporary evidence-based guidelines for acute stroke management is often delayed due to a range of key enablers and barriers. Recent reviews on such barriers focus mainly on specific acute stroke therapies or generalised stroke care guidelines. This review examined the overall barriers and enablers, as perceived by health professionals which affect how evidence-based practice guidelines (stroke unit care, thrombolysis administration, aspirin usage and decompressive surgery) for acute stroke care are adopted in hospital settings. METHODOLOGY A systematic search of databases was conducted using MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, PsycINFO, Cochrane Library and AMED (Allied and Complementary Medicine Database from 1990 to 2016. The population of interest included health professionals working clinically or in roles responsible for acute stroke care. There were no restrictions to the study designs. A quality appraisal tool for qualitative studies by the Joanna Briggs Institute and another for quantitative studies by the Centre for Evidence-Based Management were used in the present study. A recent checklist to classify barriers and enablers to health professionals' adherence to evidence-based practice was also used. RESULTS Ten studies met the inclusion criteria out of a total of 9832 search results. The main barriers or enablers identified included poor organisational or institutional level support, health professionals' limited skills or competence to use a particular therapy, low level of awareness, familiarity or confidence in the effectiveness of a particular evidence-based therapy, limited medical facilities to support evidence uptake, inadequate peer support among health professionals', complex nature of some stroke care therapies or guidelines and patient level barriers. CONCLUSIONS Despite considerable evidence supporting various specific therapies for stroke care, uptake of these therapies is compromised by barriers across organisational, patients, guideline interventions and health professionals' domains. As a result, we recommend that future interventions and health policy directions should be informed by these findings in order to optimise uptake of best practice acute stroke care. Further studies from low- to middle-income countries are needed to understand the barriers and enablers in such settings. TRIAL REGISTRATION The review protocol was registered in the international prospective register of systematic reviews, PROSPERO 2015 (Registration Number: CRD42015023481 ).
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Affiliation(s)
- Leonard Baatiema
- Regional Institute for Population Studies, University of Ghana, P.O Box LG96, Legon-Accra, Ghana.
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Sydney, Australia.
| | - Michael E Otim
- College of Health Sciences, University of Sharjah, Sharjah, United Arab Emirates
| | - George Mnatzaganian
- College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Melbourne, Australia
| | - Ama de-Graft Aikins
- Regional Institute for Population Studies, University of Ghana, P.O Box LG96, Legon-Accra, Ghana
| | - Judith Coombes
- School of Pharmacy, University of Queensland, Brisbane, Australia
| | - Shawn Somerset
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Sydney, Australia
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Baatiema L, de-Graft Aikins A, Sav A, Mnatzaganian G, Chan CKY, Somerset S. Barriers to evidence-based acute stroke care in Ghana: a qualitative study on the perspectives of stroke care professionals. BMJ Open 2017; 7:e015385. [PMID: 28450468 PMCID: PMC5719663 DOI: 10.1136/bmjopen-2016-015385] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Despite major advances in research on acute stroke care interventions, relatively few stroke patients benefit from evidence-based care due to multiple barriers. Yet current evidence of such barriers is predominantly from high-income countries. This study seeks to understand stroke care professionals' views on the barriers which hinder the provision of optimal acute stroke care in Ghanaian hospital settings. DESIGN A qualitative approach using semistructured interviews. Both thematic and grounded theory approaches were used to analyse and interpret the data through a synthesis of preidentified and emergent themes. SETTING A multisite study, conducted in six major referral acute hospital settings (three teaching and three non-teaching regional hospitals) in Ghana. PARTICIPANTS A total of 40 participants comprising neurologists, emergency physician specialists, non-specialist medical doctors, nurses, physiotherapists, clinical psychologists and a dietitian. RESULTS Four key barriers and 12 subthemes of barriers were identified. These include barriers at the patient (financial constraints, delays, sociocultural or religious practices, discharge against medical advice, denial of stroke), health system (inadequate medical facilities, lack of stroke care protocol, limited staff numbers, inadequate staff development opportunities), health professionals (poor collaboration, limited knowledge of stroke care interventions) and broader national health policy (lack of political will) levels. Perceived barriers varied across health professional disciplines and hospitals. CONCLUSION Barriers from low/middle-income countries differ substantially from those in high-income countries. For evidence-based acute stroke care in low/middle-income countries such as Ghana, health policy-makers and hospital managers need to consider the contrasts and uniqueness in these barriers in designing quality improvement interventions to optimise patient outcomes.
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Affiliation(s)
- Leonard Baatiema
- Regional Institute for Population Studies, University of Ghana, Accra, Legon, Ghana
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Sydney, Australia
| | - Ama de-Graft Aikins
- Regional Institute for Population Studies, University of Ghana, Accra, Legon, Ghana
| | - Adem Sav
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
| | - George Mnatzaganian
- College of Science, Health and Engineering, La Trobe Rural Health School, La Trobe University, Melbourne, Australia
| | - Carina K Y Chan
- School of Psychology, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
| | - Shawn Somerset
- School of Allied Health, Faculty of Health Sciences, Australian Catholic University, Brisbane, Australia
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